Name of the Procedure:

Craniotomy with Elevation of Bone Flap; for Partial or Subtotal (Functional) Hemispherectomy

Summary

A craniotomy with elevation of bone flap for partial or subtotal (functional) hemispherectomy is a surgical procedure where a portion of the skull is temporarily removed to access the brain. This is done to remove or disconnect part of one hemisphere of the brain, which is typically necessary to control severe, treatment-resistant seizures or other neurological conditions.

Purpose

The main purpose of this procedure is to treat severe epilepsy or other neurological conditions that have not responded to medication or less invasive treatments. The goal is to reduce or eliminate seizures, improve quality of life, and prevent further neurological deterioration.

Indications

• Intractable epilepsy that does not respond to medication
• Unilateral brain conditions such as Rasmussen's encephalitis, certain brain tumors, or extensive cortical dysplasias
• Severe brain injury affecting one hemisphere
• Chronic, debilitating pain or functional disturbances localized to one hemisphere

Preparation

• Fasting typically required for 8 hours before surgery
• Discontinuation or adjustment of certain medications as advised by the doctor
• Preoperative imaging tests, such as MRI or CT scans, to map the brain structures
• Blood tests, ECG, and other evaluations to assess overall health and surgical readiness

Procedure Description

1. Anesthesia: The patient is placed under general anesthesia.
2. Preparation: The scalp is shaved and disinfected.
3. Incision: A surgical incision is made in the scalp.
4. Bone Flap Removal: A portion of the skull (bone flap) is carefully removed to expose the brain.
5. Hemispherectomy: The neurosurgeon removes or disconnects the targeted parts of the affected brain hemisphere.
6. Closing: The bone flap is replaced and secured, followed by suturing the scalp incision.
7. Immediate Care: Post-operative monitoring and initial recovery in the ICU.

Tools used may include scalpels, retractors, microscopes, and advanced imaging technology.

Duration

The procedure can take 4 to 6 hours, depending on the complexity and extent of the surgery.

Setting

Performed in a hospital operating room equipped with advanced neurosurgical facilities.

Personnel

• Neurosurgeon
• Anesthesiologist
• Surgical nurses
• Operating room technicians
• Neurophysiologist (if intraoperative monitoring is required)

Risks and Complications

• Infection
• Bleeding or blood clots
• Cerebrospinal fluid leaks
• Swelling of the brain
• Neurological deficits such as weakness or speech difficulties
• Seizures
• Anesthesia-related complications

Benefits

• Significant reduction or complete cessation of seizures
• Improved quality of life
• Potential to reduce or eliminate the need for seizure medications
• Prevention of neurological deterioration

Recovery

• Close monitoring in the ICU and progressive step-down care
• Pain management with medications
• Gradual reintroduction to normal activities.
• Physical and occupational therapy may be needed.
• Follow-up appointments to monitor recovery and adjust medications.
• Full recovery may take several weeks to months, with gradual improvement.

Alternatives

• Vagus nerve stimulation (VNS)
• Responsive neurostimulation (RNS)
• Conventional antiepileptic drugs
• Less invasive brain surgeries
• Each alternative has its own set of risks, benefits, and levels of effectiveness based on the individual patient's condition.

Patient Experience

During the procedure, the patient will be under general anesthesia and will not feel any discomfort. Post-surgery, there may be pain at the incision site, headaches, and temporary neurological deficits. Pain is managed with medications. Gradual improvement and rehabilitation efforts will aid recovery. The healthcare team will focus on comfort and pain management throughout the process.